byCanadian Medical Association Journal

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Risk prediction tools might help identify patients at the highest risk of overdose and death after a "before medically advised" (BMA) hospital discharge, according to new research in theCanadian Medical Association Journal.

Patients who leave hospital against the advice of a physician are about twice as likely to die and about 10 times more likely to experience an illicitdrug overdosein the first 30 days after leaving hospital. Such BMA discharges are initiated by about 500,000 people in the United States and 30,000 people in Canada every year.

"Calculating a specific patient's risk ofdeathand drug overdose—combined with clinical judgment and other risk scores—might help clinicians and patients have a constructive, patient-centered discussion about the decision to initiate a BMA discharge, including assessing the patient's capacity to make such a decision and discussing ways to mitigate risks after BMA discharge," writes Dr. Hiten Naik, University of British Columbia, Vancouver, British Columbia, with co-authors.

"By reducing uncertainty, risk estimates might also reduce clinician moral distress when faced with a BMA discharge."

Researchers developed two risk prediction models: one to estimate the risk of death from any cause during the 30-day period after a BMA discharge, and another for patients with a history of substance use to estimate the risk of illicit drug overdose in patients with a history of substance use.

Using data from British Columbia, investigators examinedcohortA, a group of 6,440 adults from the general population who initiated a BMA discharge, and cohort B, which included 4,466 people with a history of substance use who initiated a BMA discharge.

In cohort A, researchers found that death was less common than generally expected, with one death within 30 days for every 63 BMA discharges. Multimorbidity,heart disease, and cancer were strong predictors of death within 30 days of discharge.

In cohort B, homelessness, income assistance, opioid use disorder, non-alcohol substance use disorder, drug overdose within the past year, and discharge from a surgical service were strong predictors of drug overdose after BMA discharge.

"Among patients with a history of substance use, illicit drug overdose was a relatively common outcome soon after BMA discharge (i.e., around one illicit drug overdose within 30 days for every 19 BMA discharges), suggesting this period is a critical but largely unexplored opportunity for overdose prevention," write the authors.

They suggest that hospitals andhealth systemscould use risk prediction models to automate the approach to higher-risk BMA discharges, with alerts and automatic enrollment in support programs.

"These models offer a starting point for identifying patients who are high risk and may benefit from greater support."

More information: Predicting drug overdose and death after 'before medically advised' hospital discharge, Canadian Medical Association Journal (2025). DOI: 10.1503/cmaj.250492 Journal information: Canadian Medical Association Journal

Provided by Canadian Medical Association Journal